Explain abdomen and cns clinical examination
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Abdominal & CNS Clinical Examination
PART 1: ABDOMINAL EXAMINATION
The abdominal examination follows a strict sequence: inspection → auscultation → percussion → palpation. (Note: auscultation comes before percussion and palpation to avoid artificially altering bowel sounds.)
1. Preparation & Positioning
- Patient supine, arms at sides, knees slightly flexed to relax the abdominal wall
- Bladder should be emptied before the exam
- Expose from xiphisternum to groin; maintain dignity
- Stand to the right of the patient
2. Abdominal Quadrants & Regions
For descriptive purposes the abdomen is divided into four quadrants by a vertical midline and a transverse line through the umbilicus:
| Quadrant | Key Structures |
|---|---|
| RUQ | Liver, gallbladder, head of pancreas, hepatic flexure of colon, right kidney |
| LUQ | Stomach, spleen, tail of pancreas, splenic flexure, left kidney |
| RLQ | Appendix, cecum, right ovary/tube |
| LLQ | Sigmoid colon, left ovary/tube |
Additional named regions: epigastric, umbilical, hypogastric/suprapubic, right and left flanks.
3. Inspection
Examine the abdomen visually for:
- Scars — prior surgery or trauma
- Asymmetry — suggests a mass or organomegaly
- Distension — obesity, ascites, intestinal obstruction/ileus
- Prominent periumbilical veins (caput medusae) — portal hypertension
- Hernias — umbilical, ventral, inguinal
- Pulsation — aortic aneurysm
- Skin changes — jaundice, spider angiomata, striae
4. Auscultation
- Listen for bowel sounds using the diaphragm of the stethoscope
- Absent → ileus, peritonitis, anticholinergic poisoning
- Hyperactive → gastroenteritis, early obstruction, cholinergic toxicity
- Listen for bruits over the aorta, renal arteries, and iliac arteries (renovascular hypertension, aortic stenosis)
- In patients without abdominal pain, auscultation of bowel sounds has limited usefulness and may be omitted
5. Percussion
Performed before or in conjunction with palpation:
- General percussion — map areas of dullness (solid organs, fluid) vs. tympany (gas)
- Liver size — percuss upper border (dullness at 5th–7th intercostal space, MCL) and lower border (transition to tympany); normal span is 6–12 cm in the MCL
- Spleen — percuss over left 10th rib, posterior to midaxillary line; dullness distinct from gastric tympany suggests splenomegaly
- Ascites:
- Flanks dull in supine position → shifting dullness on lateral roll = most sensitive test
- Fluid thrill (wave) in moderate–large ascites
6. Palpation
Light Palpation
- Use 4 fingertips, depress 1–2 cm
- Detects muscle guarding (involuntary), superficial tenderness, and abdominal wall masses
- Start away from the site of pain
Deep Palpation
- Depress 4–5 cm
- Assess for: liver, spleen, kidneys, aorta, and masses
Liver: During held inspiration, palpate along the right costal margin with the right hand starting in the RLQ; assess size, contour, texture, tenderness. Hepatomegaly: liver edge felt >2 cm below costal margin.
Spleen: Support left costal margin with your left hand; palpate below right costal margin during inspiration. Normal spleen usually not palpable; enlargement must be 2–3× normal size to detect.
Kidneys: Bimanual technique — one hand posteriorly under the flank, the other on the anterior abdominal wall. Kidneys descend on deep inspiration.
Aortic pulsation: Deep midline palpation for expansile pulsation (AAA if width >3 cm).
7. Special Signs
| Sign | Technique | Significance |
|---|---|---|
| Murphy's sign | Press below right costal margin, ask patient to inspire; positive = patient catches breath | Acute cholecystitis |
| McBurney's point tenderness | Tenderness 1/3 from ASIS to umbilicus | Appendicitis |
| Rovsing's sign | LLQ pressure causes RLQ pain | Appendicitis |
| Psoas sign | Right thigh hyperextension increases pain | Retrocecal appendicitis |
| Obturator sign | Internal rotation of right hip causes pain | Pelvic appendix/abscess |
| Carnett's sign | Tenderness increases with head raise (tenses abdominal wall) | Abdominal wall origin |
| Rebound tenderness | Rapid release of deep pressure causes pain | Peritoneal irritation |
8. Anorectal Examination
An important component often omitted:
- External inspection: rashes, soilage (fistula/incontinence), fissures, fistulas, skin tags, external/prolapsed hemorrhoids
- Digital rectal exam: anal sphincter tone, resting and squeeze pressure; sweep for masses, tenderness, fluctuation
- Indicated in: perianal/rectal symptoms, incontinence, difficult defecation, IBD, acute abdominal pain, GI bleeding (stool color and occult blood testing)
PART 2: CNS (NEUROLOGICAL) EXAMINATION
The neurological examination is traditionally divided into five major areas:
- Mental Status
- Cranial Nerves
- Motor System
- Sensory System
- Reflexes
(Some schemes add: higher cerebral functions, cerebellar testing, and gait/station as separate components.)
1. General Approach & Observation
Neurological assessment begins during the history:
- Hypomimia (reduced facial expression) → Parkinson's disease or depression
- Worried/astonished expression → progressive supranuclear palsy
- Ptosis → myasthenia gravis or brainstem lesion
- Speech pattern → dysarthria, aphasia, spasmodic dysphonia
- Involuntary movements → movement disorder
2. Mental Status Examination
Assesses appearance/behavior, consciousness, speech, mood, thought content, and cognition.
Key domains:
- Level of consciousness: alert, drowsy, stuporous, comatose
- Orientation: person, place, time, situation
- Attention: digit repetition (normal: 6–7 forward, 4–5 backward); failure suggests delirium/confusion
- Memory:
- Short-term: 3-object recall at 5 minutes
- Long-term: recall of past events
- Language:
- Broca's aphasia: non-fluent speech, comprehension preserved
- Wernicke's aphasia: fluent but meaningless speech, poor comprehension
- Conductive aphasia: poor repetition but comprehension intact
- Dysarthria: mechanical articulation problem (not a language disorder)
- Higher functions: clock drawing, constructional tasks; errors suggest parietal/frontal lobe damage
- Screening tool: Mini-Mental State Examination (MMSE)
3. Cranial Nerve Examination
| CN | Name | Test |
|---|---|---|
| I | Olfactory | Test smell unilaterally; reserved for head injury, Parkinson's, anosmia |
| II | Optic | Visual acuity (each eye separately), visual fields by confrontation, fundoscopy (papilledema, hemorrhage, disc atrophy), swinging flashlight test (afferent pupillary defect) |
| III, IV, VI | Oculomotor, Trochlear, Abducens | Pupil size/symmetry/reactivity to light; horizontal and vertical eye movements (saccades, pursuit, VOR); nystagmus; ptosis |
| V | Trigeminal | Pinprick and light touch on face (3 divisions); corneal reflex; jaw strength/deviation |
| VII | Facial | Close eyes against resistance; show teeth; forehead wrinkling (upper vs. lower motor neuron); taste (anterior 2/3 tongue) |
| VIII | Vestibulocochlear | Whispered voice in each ear; Rinne and Weber tests; vestibular function (nystagmus, Romberg) |
| IX, X | Glossopharyngeal, Vagus | Palate elevation (uvula deviates away from lesion); gag reflex; voice quality (hoarseness) |
| XI | Accessory | Sternocleidomastoid (head turning) and trapezius (shoulder shrug) strength |
| XII | Hypoglossal | Tongue protrusion (deviates toward paretic side); assess for atrophy, fasciculations |
4. Motor Examination
Assess: body posture, bulk, tone, strength, involuntary movements, coordination, gait.
Muscle Bulk & Tone
- Atrophy → LMN or disuse
- Tone tested by passive flexion/extension of limb:
- Spasticity (velocity-dependent) → corticospinal tract lesion (UMN)
- Rigidity / cogwheeling → basal ganglia/extrapyramidal lesion (Parkinson's)
- Flaccidity → LMN lesion or acute UMN ("spinal shock")
Muscle Strength (MRC Scale)
| Grade | Description |
|---|---|
| 5 | Normal strength |
| 4 | Weak but moves against gravity + some resistance |
| 3 | Movement against gravity only |
| 2 | Movement with gravity eliminated |
| 1 | Flicker of contraction only |
| 0 | No contraction |
Pronator Drift Test
Hold arms outstretched, palms up, eyes closed → downward or inward rotation of one arm indicates subtle contralateral UMN weakness.
UMN vs. LMN Distinction
| Feature | UMN | LMN |
|---|---|---|
| Tone | Increased (spasticity) | Decreased (flaccidity) |
| Reflexes | Hyperreflexia | Hyporeflexia/areflexia |
| Plantar | Extensor (Babinski +) | Flexor |
| Wasting | Mild, late | Early, pronounced |
| Fasciculations | Absent | Present |
Involuntary Movements
- Tremor: resting (Parkinson's) vs. action/intention (essential, cerebellar)
- Chorea: random, dance-like
- Myoclonus: sudden jerks
- Dystonia: sustained abnormal postures
5. Coordination Testing
- Finger-nose-finger test: alternately touch nose then examiner's finger (moved between trials); tests cerebellar hemisphere
- Heel-knee-shin test: slide heel down opposite shin smoothly
- Rapid alternating movements (dysdiadochokinesia): finger tapping, supination/pronation
- Romberg test: feet together, eyes open then closed; positive (falls with eyes closed) = proprioceptive loss (dorsal column or peripheral nerve) — if falls with eyes open, more likely cerebellar
Cerebellar lesions produce: intention tremor, past-pointing, dysdiadochokinesia, ataxic gait — ipsilateral to the lesion.
6. Gait Assessment
- Ask patient to walk normally → observe stride length, arm swing, posture, heel-strike, toe-off
- Tandem (heel-to-toe) gait — sensitive for cerebellar/proprioceptive deficit
| Gait Pattern | Cause |
|---|---|
| Hemiplegic (circumduction) | Unilateral UMN lesion |
| Spastic/scissor | Bilateral UMN (spinal cord) |
| Steppage | Foot drop (common peroneal nerve, L4/L5) |
| Waddling | Proximal myopathy/pelvic girdle weakness |
| Parkinsonian | Stooped, shuffling, festinating, reduced arm swing |
| Ataxic | Wide-based, cerebellar disease |
| Sensory ataxic | Stamping, worse in dark/eyes closed |
7. Sensory Examination
Requires an alert and cooperative patient. Test each modality systematically over major dermatomes; compare side to side.
| Modality | Technique | Pathway |
|---|---|---|
| Light touch | Cotton wisp over dermatomes | Dorsal columns + spinothalamic |
| Pinprick | Neurological pin; compare sides | Spinothalamic tract (contralateral) |
| Temperature | Hot/cold objects | Spinothalamic (same as pain) |
| Vibration | 128-Hz tuning fork on bony prominences | Dorsal columns (ipsilateral) |
| Proprioception (joint position) | Hold digit sides, move up/down; patient identifies direction | Dorsal columns (ipsilateral) |
Cortical sensory tests (require intact primary sensation):
- Stereognosis: identify objects by touch alone
- Graphesthesia: identify numbers written on palm
- Two-point discrimination
- Sensory extinction: double simultaneous stimuli (parietal lobe lesion)
Spinothalamic tract: pain, temperature, crude touch — crosses at level of cord entry → contralateral deficits
Dorsal columns: vibration, proprioception, fine touch — ascend ipsilaterally → deficits ipsilateral to lesion
8. Reflex Examination
Deep Tendon Reflexes (DTRs)
Graded 0–4+:
| Grade | Description |
|---|---|
| 0 | Absent |
| 1+ | Diminished |
| 2+ | Normal |
| 3+ | Brisk (normal variant) |
| 4+ | Clonus (pathological) |
| Reflex | Root Level |
|---|---|
| Biceps | C5–C6 |
| Brachioradialis | C6 |
| Triceps | C7 |
| Knee (patellar) | L3–L4 |
| Ankle (Achilles) | S1 |
Hyperreflexia → UMN lesion | Hyporeflexia/areflexia → LMN lesion, peripheral neuropathy, acute spinal shock
Plantar Response (Babinski Sign)
- Stroke the lateral sole from heel to ball then across the metatarsal heads
- Normal (flexor): toes curl down
- Abnormal (extensor/Babinski +): great toe extends, other toes fan out → UMN lesion above L1
Other Pathological Reflexes
- Hoffman's sign: flick distal phalanx of middle finger → index/thumb flexion → UMN (cervical myelopathy)
- Clonus: sustained rhythmic jerking with rapid dorsiflexion of ankle → UMN
- Glabellar tap: repeated tapping of forehead → sustained blinking = parkinsonism (failure to habituate)
9. Glasgow Coma Scale (GCS) — for impaired consciousness
| Component | Score |
|---|---|
| Eye opening: Spontaneous / To speech / To pain / None | 4 / 3 / 2 / 1 |
| Verbal: Oriented / Confused / Inappropriate words / Sounds / None | 5 / 4 / 3 / 2 / 1 |
| Motor: Obeys / Localizes / Withdraws / Flexion / Extension / None | 6 / 5 / 4 / 3 / 2 / 1 |
Maximum = 15 (normal); ≤8 = coma by convention.
The FOUR Score (Full Outline of Unresponsiveness) is more comprehensive for brainstem function, including respiratory patterns — particularly useful in intubated patients.
Quick Screening Neurological Exam (Table Summary)
| Component | Test |
|---|---|
| Mental status | Assessed during history |
| CN II | Visual acuity, fields, swinging flashlight |
| CN III/IV/VI | Eye movements, pupil reflexes, fundoscopy |
| CN V | Facial sensation, corneal reflex |
| CN VII | Eye closure, smile symmetry |
| CN VIII | Whispered voice |
| CN IX/X | Palate, gag |
| CN XII | Tongue protrusion |
| Motor | Pronator drift, strength grading |
| Coordination | Finger-nose-finger, heel-knee-shin |
| Gait | Normal walk + tandem |
| Reflexes | Biceps, triceps, knee, ankle, plantar |
| Sensation | Pinprick, vibration, proprioception (fingers/toes) |
Sources: Goldman-Cecil Medicine, 26th ed. | Textbook of Family Medicine, 9th ed. | Tintinalli's Emergency Medicine | Bradley and Daroff's Neurology in Clinical Practice | Adams and Victor's Principles of Neurology, 12th ed.
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